Polyaxial bone anchoring device with enlarged pivot angle

ABSTRACT

A polyaxial bone anchoring device is provided including an anchoring element ( 1 ) having a shank ( 2 ) for anchoring in the bone and a head ( 3 ), the head comprising a spherically-shaped outer surface portion ( 3   a ); a receiving part ( 4 ) configured to be pivotably connected to said head ( 3 ), the receiving part having a first end ( 4   a ), a second end ( 4   b ), a central axis (C) extending through the first end ( 4   a ) and the second end ( 4   b ), a channel ( 42 ) for receiving a rod ( 100 ), an accommodation space ( 44 ) for accommodating the head ( 3 ), the accommodation space ( 44 ) having a lower opening ( 45 ) at the second end ( 4   b ), and a coaxial passage ( 41 ) extending from the first end ( 4   a ) into the accommodation space ( 44 ), a cap member ( 6, 6 ′) that is arranged at least partially in the accommodation space ( 44 ), the cap member ( 6, 6 ′) having a first portion ( 61 ) that is configured to be positioned at least partially around the head ( 3 ), wherein the first portion ( 61 ) is expandable in the accommodation space ( 44 ) to allow insertion of the head ( 3 ) and compressible to exert pressure onto the head ( 3 ); a sleeve-like insert piece ( 5 ) configured to be positioned at least partially around the first portion ( 61 ) of the cap member ( 6, 6 ), wherein the sleeve-like insert piece ( 5 ) comprises a spherically-shaped outer surface portion ( 51 ) and is configured to pivot in the receiving part ( 4 ).

CROSS-REFERENCE TO RELATED APPLICATION(S)

The present application claims priority to and the benefit of U.S. Provisional Patent Application Ser. No. 61/904,403, filed Nov. 14, 2013, the contents of which are hereby incorporated by reference in their entirety, and claims priority from European Patent Application EP 13 192 978.8, filed Nov. 14, 2013, the contents of which are hereby incorporated by reference in their entirety.

BACKGROUND

1. Field

The invention relates to a polyaxial bone anchoring device with an enlarged pivot angle. The bone anchoring device includes a bone anchoring element for anchoring in a bone or a vertebra, and a receiving part for coupling the bone anchoring element to a stabilization element such as a spinal rod, where the bone anchoring element is pivotable relative to the receiving part and can be pivoted out of a central axis with an enlarged pivot angle. The orientation of the enlarged pivot angle may be selectable within a range of 360° around the central axis. The bone anchoring element is insertable into the receiving part from a bottom end of the receiving part.

2. Description of Related Art

A polyaxial bone anchoring device with an enlarged pivot angle that is selectable within a range of 360° around a central axis of the receiving part is known from US 2012/0136395 A1. This polyaxial bone anchoring device includes a sleeve-like insert piece that is positioned around a portion of the head of the bone anchoring element and that is configured to pivot in an accommodation space of the receiving part. The anchoring element and the insert piece can be locked at respective angles relative to the central axis of the receiving part. An enlarged pivot angle may be automatically achieved by pivoting the receiving part relative to the bone anchoring element in a specific direction. In one embodiment, the bone anchoring element may be inserted from the top end of the receiving part. In another embodiment, the bone anchoring element together with the sleeve-like insert piece may be inserted from the bottom end of the receiving part.

A polyaxial bone anchoring device of the bottom loading type are known, for example, from US 2010/0234902 A1.

SUMMARY

It is the object of the invention to provide an polyaxial bone anchoring device that allows to pivot the bone anchoring element at an enlarged pivot angle in at least one direction and that is improved in terms of a modular, robust design.

The polyaxial bone anchoring device according to embodiments of the invention is a bottom loading type bone anchoring device, where the anchoring element is insertable from the bottom end of the receiving part. A compressible cap member encompasses at least a portion of the head of the bone anchoring device. The cap member is seated in a sleeve-like insert piece that is solid, i.e. without slits or elastic portions. Consequently, the sleeve-like insert piece has a higher strength compared to a flexible sleeve of the same or similar dimensions. That renders the construct robust, because high clamping forces can be exerted onto the cap member that are taken up by the sleeve-like insert piece.

The cap member is sized such that the head is held therein by friction even if no pressure is exterted onto the cap member. When the receiving part is pivoted in order to align it for insertion of the rod, the angular position of the receiving part relative to the bone anchoring element is maintained and can be changed by overcoming the friction force. This allows a convenient handling of the device during surgery.

At at least one side of its lower edge the cap member may have a recess or a cut portion that allows to pivot the anchoring element at a larger angle in the direction where the recess or cut portion is located compared to the opposite direction or to another direction. An indication mark provided at the cap member may indicate the orientation of the enlarged pivot angle when the cap member is arranged in the receiving part and may cooperate with a tool that indicates the orientation to a user. The cap member is configured to rotate in the receiving part when no pressure is exerted onto it so that the orientation of the enlarged pivot angle may be adjusted within a range of 360° around the central axis of the receiving part. The enlarged pivot angle may be greater than or equal to around 40° measured from the central axis of the receiving part.

A separate rod receiving element may be provided that is arranged in the receiving part on top of the cap member. The rod receiving element provides a seat for the rod and is configured to transmit pressure onto the cap member. It may be held by a first retaining element such that it cannot escape through the top end of the receiving part when the head is inserted into the cap member. Further, the rod receiving element may be held in a more downward position by a second retaining element such that the cap member is surrounded at least partially by the sleeve-like insert piece. In this position, the head of the bone anchoring element is in a pre-locking position wherein it is prevented from removal through the bottom end but not yet locked.

The rod receiving element may have side walls that extend above the surface of an inserted rod. This renders it suitable for use with a single part locking element that is configured to lock the head and the rod at the same time or sequentially or for use with a two-part locking element that is configured to lock the head and the rod independently.

The receiving part, the sleeve-like insert piece and the cap member may be pre-assembled and the bone anchoring device can be inserted into the pre-assembled device from the bottom end of the receiving part in an easy manner. This allows to first insert the bone anchoring element into the bone and to mount the receiving part thereafter, By means of this design a modular system can be provided where the surgeon or any other personnel can select a suitable bone anchoring element such as a screw or a nail with a particular length and/or diameter, cannulated or non cannulated and various other features and combine it with the pre-assembled receiving part. Lastly, the system allows to select a suitable closure mechanism.

BRIEF DESCRIPTION OF THE DRAWINGS

Further features and advantages of the invention will become apparent from the description of embodiments by means of the accompanying drawings. In the drawings:

FIG. 1 shows a perspective exploded view of a polyaxial bone anchoring device with a spinal rod according to a first embodiment;

FIG. 2 shows a perspective view of the bone anchoring device of FIG. 1 in an assembled state;

FIG. 3 shows a cross-sectional view of the bone anchoring device of FIGS. 1 and 2 in the assembled state with an inserted rod, the section being taken along a rod axis;

FIG. 4 shows a perspective view from a side of a receiving part of FIG. 1;

FIG. 5 shows a perspective view from the bottom of the receiving part of FIG. 4;

FIG. 6 shows a top view of the receiving part of FIGS. 4 and 5;

FIG. 7 shows a cross-sectional view of the receiving part of FIGS. 4 to 6 along line A-A in FIG. 6;

FIG. 8 shows a perspective view from the top of the sleeve-like insert piece of FIG. 1;

FIG. 9 shows a perspective view from the bottom of the sleeve-like insert piece of FIG. 8;

FIG. 10 shows a top view of the sleeve-like insert piece of FIGS. 8 and 9;

FIG. 11 shows a cross-sectional view of the sleeve-like insert piece of FIGS. 8 to 10 along line B-B in FIG. 10;

FIG. 12 shows a perspective view from the top of a cap member of FIG. 1;

FIG. 13 shows a perspective view from the bottom of the cap member of FIG. 12;

FIG. 14 shows a top view of the cap member of FIGS. 12 and 13;

FIG. 15 shows a cross-sectional view of the cap member of FIGS. 12 to 14 along line C-C in FIG. 14;

FIG. 16 shows a perspective view from the side of a rod receiving element of FIG. 1;

FIG. 17 shows a perspective view from the bottom of the rod receiving element of FIG. 16;

FIG. 18 shows a top view of the rod receiving element of FIGS. 16 and 17;

FIG. 19 shows a cross-sectional view of the rod receiving element of FIGS. 16 to 18 along line D-D in FIG. 18;

FIG. 20 shows a cross-sectional view of a first step of assembling the receiving part and the sleeve-like insert piece of the polyaxial bone anchoring device according to the first . embodiment, the section taken perpendicular to a rod axis;

FIG. 21 shows a cross-sectional view of a second step of assembling the receiving part and the sleeve-like insert piece of the polyaxial bone anchoring device according to the first embodiment;

FIG. 22 shows a cross-sectional view of a third step of assembling the polyaxial bone anchoring device, wherein the cap member is inserted;

FIG. 23 shows a cross-sectional view of a fourth step of assembling the polyaxial bone anchoring device, wherein the rod receiving element is inserted;

FIG. 24 shows a cross-sectional view of a first step of inserting the bone anchoring element into the receiving part that is pre-assembled with the sleeve-like insert piece, the cap member and the rod receiving element;

FIG. 25 shows a second step of inserting the bone anchoring element into the receiving part;

FIG. 26 shows a cross-sectional view of a third step of inserting the bone anchoring element into the receiving part;

FIG. 27 shows a cross-sectional view of the receiving part with pre-assembled sleeve-like insert piece, cap member and rod receiving element and inserted head of the bone anchoring element in a pre-locking condition;

FIG. 28 shows a perspective view from the side of a second embodiment of the cap member of the polyaxial bone anchoring device;

FIG. 29 shows a perspective view from the bottom of the cap member of FIG. 28;

FIG. 30 shows a top view of the cap member of FIGS. 28 and 29; and

FIG. 31 shows a cross-sectional view of the cap member of FIGS. 28 to 30 along line F-F in FIG. 30.

DETAILED DESCRIPTION

As shown in FIGS. 1 to 3, a polyaxial bone anchoring device according to a first embodiment includes a bone anchoring element 1 in the form of a bone screw having a threaded shank 2 and a head 3. The head 3 typically has a spherically-shaped outer surface portion 3 a and a recess 3 b at its free end for engagement with a driver or tool. The spherically-shaped outer surface portion 3 a of the head includes a portion with a greatest outer diameter E of the head 3. The head 3 may be held in a receiving part 4 that couples the bone anchoring element 1 to a stabilization rod 100. In the receiving part 4, a sleeve-like insert piece 5 and a cap member 6 that is seated in the sleeve-like insert piece 5 and that exerts pressure onto the head 3 are arranged. Furthermore, a separate rod receiving element 7 is provided for receiving the rod 100 and for transmitting pressure onto the cap member 6. A locking device 8 comprising a first locking element 8 a and a second locking element 8 b is also provided for securing and fixing the rod 100 in the receiving part 4.

As depicted more in detail in FIGS. 3 to 7, the receiving part 4 has a first end forming in the position of ordinary use a top end 4 a and a second end forming in the ordinary position of use a bottom end 4 b, a central axis C and a passage 41 extending from the top end 4 a in the direction of the bottom end 4 b. Adjacent to the top end 4 a, a substantially U-shaped recess 42 is provided that forms a channel for receiving the rod 100. By means of the recess 42, two free legs are formed which are provided with an internal thread 43 for cooperating with the first locking element 8 a.

The passage 41 that may be a coaxial bore opens into an accommodation space 44 provided in a lower part of the receiving part 4 (e.g., nearer to the bottom end 4 b). The accommodation space 44 has a lower opening 45 at the bottom end 4 b of the receiving part 4. The accommodation space 44 further includes a seat portion 46 near the bottom end 4 b of the receiving part 4 in that the sleeve-like insert piece 5 may be seated. The seat portion 46 has a spherical shape, in order to provide a socket for a ball-and-socket joint that is formed by the sleeve-like insert piece 5 and the receiving part 4. It should be noted that the seat portion 46 can also be tapered, or can have various other shapes that can be used to realize a ball-and-socket joint. An inner diameter of the lower opening 45 is smaller than an inner diameter of a middle portion of the accommodation space 44. It shall also be noted that an inner diameter of the passage 41 does not need to be constant between the top end 4 a and the accommodation space 44, The passage 41 may have different portions with different diameters.

In order to allow the sleeve-like insert piece 5 to be inserted from the top end 4 a, two opposed recesses 47 a, 47 b are formed in the inner wall of the passage 41 and the accommodation space 44. The recesses 47 a, 47 b are aligned with the U-shaped recess 42 and extend from a bottom of the U-shaped recess 42 into the accommodation space 44. The size of the recesses 47 a, 47 b are such that the sleeve-like insert piece 5 can be inserted from the top end 4 a in a 90° tilted position, i.e. the widths of the recesses 47 a, 47 b are greater than a height of the sleeve-like insert piece 5 in its axial direction. The distance between the bottom of the recesses 47 a, 4 b in a direction transverse to the central axis C is greater than a maximum outer diameter of the sleeve-like insert piece. The recesses 47 a, 4 b extend into the accommodation space 44 to such an extent that tilting of the insert piece 5 into the seat portion 46 is possible.

Furthermore, the receiving part 4 has at least one pin hole 48 for receiving a pin 9 that forms a retaining element to retain the pieces within the receiving part 4. The pin hole 48 may be arranged at 90° relative to the channel axis of the U-shaped recess 42. Optionally, a second pin (not shown) may be provided on, for example, an opposite side of the receiving part 4.

At the end of the internal thread 43 that faces toward the bottom end 4 b of the receiving part, an undercut portion 49 is provided, the upper edge 49 a of which forms a stop for the rod receiving element 7 as described more in detail below. The undercut portion 49 thus forms two ring-segment shaped grooves with a depth that is larger than an inner diameter of the passage 41 between the internal thread 43 and the accommodation space 44.

The sleeve-like insert piece 5 is shown in more detail in FIGS. 8 to 11. The sleeve-like insert piece 5 has an upper edge 5 a and a lower edge 5 b. Between the upper edge 5 a and the lower edge 5 b the sleeve-like insert piece may have a spherically-shaped outer surface portion 51. A largest outer diameter of the sleeve-like insert piece 5 is greater than the inner diameter of the lower opening 45 of the receiving part 4. Hence, the sleeve-like insert piece 5 cannot escape through the lower opening 45 when it is seated in the receiving part 4. The dimension or shape of the outer spherical surface portion 41 corresponds to that of the spherically-shaped seat portion 46 of the receiving part 4 in such a way that the sleeve-like insert piece 5 can pivot and rotate in the receiving part 4 when the insert piece 5 is seated in the seat portion 46. When the sleeve-like insert piece 5 rests in the seat portion 46, such that its central axis 5 c is coaxial with the central axis C of the receiving part 4, the lower edge 5 b projects out of the lower opening 45 of the receiving part. When the sleeve-like insert piece 5 is pivoted or angled in the receiving part 4, as shown, for example, in FIG. 3, at least a portion of the lower edge 5 b still projects out of the lower opening 45.

The sleeve-like insert piece 5 is hollow and has a central portion 52 that is spherically-shaped with a radius corresponding to a radius of a spherically-shaped outer surface portion of the cap member which is described below. A lower end of the central portion 52 forms a shoulder 53. An inner diameter of the shoulder 53 is smaller than a largest outer diameter of the spherically-shaped portion of the cap member when the head 3 is inserted into the cap member 6, so that the cap member 6 with inserted head 3 can rotate and pivot in the central spherical portion 52 of the sleeve-like insert piece 5, similar to a ball-and-socket joint, and the head 3 cannot be removed through the bottom end 4 b of the receiving part when the spherical surfaces of the sleeve-like insert piece 5 and the cap member 6 are engaged. Between the shoulder 53 and the lower edge 5 b, a tapered portion 54 is provided that widens in the direction of the lower edge 5 b to allow angulation of the bone anchoring element 1 until the shank 2 comes into contact with the lower edge 5 b. Between the spherical central portion 52 and the upper edge 5 a, a tapered portion 55 is provided . which widens in the direction of the upper edge 5 a. An inner diameter of the tapered portion 55 and of a transition between the tapered portion 55 and the spherical portion 52 are greater than a largest outer diameter of the flexible portion of the cap member, so that the cap member 6 with inserted head 3 can move from the upper edge 5 a into the spherical central portion 52 of the sleeve-like insert piece.

Center points of the spherical central portion 52 and the outer spherical portion 51 may be the same in an axial direction. However, the center point of the central spherical portion 52 may also be shifted in the direction toward the lower edge 5 b relative to the center point of the outer spherical portion 51. This may increase the range of angulation of the bone anchoring element 1 further. A height of the sleeve-like insert piece 5 in an axial direction is less than a height of the head 3 in an axial direction, such that when the head 3 is inserted into the cap member 6 and the cap member 6 is inserted into the sleeve-like insert piece 5, as shown in FIG. 3 and for example in FIG. 25, a portion of the spherical outer surface 3 a of the head 3 may still project from the upper edge 5 a of the sleeve-like insert piece 5.

The cap member 6 will be described referring to FIGS. 1 to 3 and 12 to 15. The cap member 6 is a pressure member that is configured to clamp the head 3 upon compression of a portion of the cap member 6. It comprises a first or upper end 6 a and an opposite second or lower end 6 b and a central axis 6 c extending through the upper end 6 a and the lower end 6 b. When the cap member is inserted into the receiving part 4, the central axis 6 c of the cap member is coaxial with the central axis C of the receiving part.

Adjacent to the lower end 6 b, the cap member 6 comprises a first portion 61 that is flexible in such a way that it can be compressed and expanded in a radial direction. The first portion 61 has a hollow interior chamber 62 that is substantially spherically-shaped to clamp the spherical head 3 therein. At the lower end 6 b, an opening 63 is provided for inserting the head 3 through the opening 63 into the hollow interior chamber 62. The outer surface of the first portion 61 comprises a spherically-shaped portion that is configured to cooperate with the central spherically-shaped portion 52 of the sleeve-like insert piece 5. The shape of the first portion 61 resembles that of a cap that is to be placed on the head 3. A plurality of slits 64 extend from the lower end 6 b through the first portion 61 in a direction toward the upper end 6 a. The slits 64 are open toward the lower end 6 b and closed at the opposite end where they may have an enlarged, area 64 a to facilitate compression or expansion of the first portion 61. The enlarged area 64 a may have a circular shape. The number and dimensions of the slits 64 are such that the wall of the first portion 61 is flexible enough to snap onto the head 3 when the head 3 is inserted.

The size of the first portion 61 in the axial direction is such that when the head 3 is inserted fully into the cap member 6, the lower end 6 b of the cap member 6 extends beyond a portion of the head 3 that includes the largest diameter E of the head 3 in the direction toward the shank 2. A maximum outer diameter of the first portion 61 of the cap member 6 in the neutral position of the first portion 61, i.e. when it is neither compressed nor expanded, is smaller than an inner diameter of the accommodation space 44 and also smaller than an inner diameter of the upper tapered portion 55 of the sleeve-like insert piece 5. Therefore, it is possible to insert the head 3 through the opening 63 into the cap member 6 when the cap member is placed in the receiving part 4 and its first portion 61 extends into the accommodation space 44 and partially into the sleeve-like insert piece 5.

The dimension of the cap member 6 relative to the head 3 is such that when the head 3 is inserted through the lower opening 63 into the hollow interior chamber 62 of the cap member 6 it is held therein by friction. That means, an angular position of the bone anchoring element relative to the cap member 6 can be adjusted by applying a force that overcomes the friction force.

The cap member 6 further has a lower slanted edge portion 65 at its lower end 6 b where the cap member 6 is shorter in an axial direction over a particular range of angles around the central axis 6 c compared to the opposite side. The slanted edge portion 65 may be achieved by cutting away a portion of the cap member 6 in an inclined cut, By means of this, the bone anchoring element abuts with its shank 2 against the lower edge 6 b of the cap member at a larger angle in the direction of the slanted lower edge portion 65 as compared to the opposite direction, An enlarged pivot angle can be achieved by other means also, for example, instead of the slanted lower edge portion 65, a recess can be provided that allows the shank 2 to extend more outwardly as in an opposite direction.

The cap member 6 further comprises adjacent to the flexible first portion 61 a non-flexible second portion 66 that has a substantially cylindrical outer shape with an outer diameter that is only slightly smaller than an inner diameter of the passage 41 in the receiving part 4 so that the second portion 66 can move in the passage 41, Due to the cylindrical shape, the second portion 66 is rotatable in the receiving part 4. The cap member 6 additionally comprises a coaxial bore 67 that extends from the upper end 6 a into the hollow interior chamber 62. As can be seen in particular in FIG. 14, by means of the coaxial recess 67 a ring-shaped flat upper surface is formed at the upper end 6 a. This surface serves for cooperating with a lower surface of the rod receiving element 7 to be described below.

In the inner wall forming the coaxial bore 67, a single recess 68 is formed that serves as an indication mark for indicating the position of the slanted lower edge portion 65 that provides the enlarged pivot angle. The recess 68 is aligned with the slanted lower edge portion 65 in a circumferential direction so that even if in a top view the position of the slanted lower edge portion 65 cannot be seen, the recess 68 indicates the position of the slanted lower edge portion 65. The recess 68 may be used for cooperation with a corresponding tool that engages the cap member 6, for example through the coaxial bore 67 and that has a corresponding indication mark, such as a projection, for example, that indicates a specific orientation in circumferential direction around the central axis 6 c. Hence, by rotating the cap member 6 the orientation of the enlarged pivot angle can be adjusted to a desired orientation.

Referring now to FIGS. 1 and 16 to 19, the rod receiving element 7 is a part that is separate from the cap member 6. It is a substantially cylindrical part that comprises a first or upper end 7 a with a free end surface and an opposite second or lower end 7 b with a free end surface. Adjacent to the first end there is a substantially rectangular recess 71 that cuts out such a portion of the cylinder that two free upstanding legs 71 a, 71 b remain. Adjacent to the lower end 7 b there is an opening 72, preferably a circular opening that extends through the rod receiving element 7 into the recess 71. An inner diameter of the opening 72 is greater than the inner diameter of the coaxial bore 67 of the cap member 6 so that the end surface of the lower end 7 b is configured to fully contact the upper end surface of the upper end 6 a of the cap member 6.

On the bottom of the recess 71 between the legs 71 a and 71 b, two concave cylinder-segment shaped rod supporting projections 73 a, 73 b are provided on both sides of the opening 72. The radius of the concave portions 73 a, 73 b is preferably selected such that it is adapted to the radius of the specific rod to be used. The rod supporting projections 73 a, 73 b may be separated from the legs 71 a, 71 b by a groove 74 on each side of the projections. The width of the recess 71 is such that the rod 100 can be received in the recess 71. When the rod 100 is inserted into the recess 71 of the rod receiving element 7, it can rest on the rod supporting projections 73 a, 73 b. A height of the legs 71, 71 b is such that the upper end 7 a is located above the upper rod surface when the rod 100 is placed into the channel 71 and rests on the rod supporting projections 73 a, 73 b as shown in FIG. 3.

An outer diameter of the rod receiving element 7 is only slightly smaller than an inner diameter of the passage 41 of the receiving part 4 so that the rod receiving element 7 can move in the passage 41 to some extent and is guided therein.

The rod receiving element 7 further comprises at each leg 71 a, 71 b an elongate recess 75 that extends substantially from the bottom of the recess 71 to a distance from the first end 7 a. The recesses 75 extend completely through each leg 71 a, 71 b in a radial direction. They have such -a width that the pin 9 can be accommodated therein. A bottom end 75 a of each elongate recess 75 forms a stop for the pin 9 that extends into one recess. The stop prevents the rod receiving element 7 from escaping through the first end 4 a of the receiving part 4 when the cap member 6 is in an insertion position. Furthermore, the recesses 75 may serve with the at least one pin 9 as a securing device to maintain the alignment between the recess 42 of the receiving part 4 and the channel 71 of the rod receiving element 7. The pin 9 forms a first retaining element that secures the pre-assembled receiving part 4 with the sleeve-like insert piece 5, the cap member 6 and the rod receiving element 7 against loss of in particular the rod receiving element 7 and/or the cap member 6. Providing two recesses 75, one on each side, allows to insert the rod receiving element 7 into the receiving part 4 in two orientations that are offset by 180°. This is convenient, for example, if only one pin 9 is used.

In addition, the rod receiving element 7 has on each leg 71 a, 71 b, at a position above the recesses 75, a circumferentially extending projection 76 with a flat upper surface 76 a and an inclined lower surface 76 b. A maximum outer diameter of the projections 76 is slightly larger than an inner diameter of the internal thread 73. When the rod receiving element 7 is inserted into the passage 41, the legs 71 a, 71 b are slightly compressed, so that the rod receiving element 7 can be moved downward which is possible due to the inclination of the lower side 76 b of the projection. As explained more in detail below, the projection 76 is configured to enter into the undercut portion 49 and the upper edge 49 a of the undercut portion 49 forms a second retaining element that cooperates with the flat upper surface 76 a of the projection 76 to prevent upward movement of the rod receiving element 7.

Furthermore, on each leg 71, 71 b, a longitudinally extending cylinder segment-shaped recess 77 is provided that extends from the bottom of the recess 71 to the first end 7 a.

The bone anchoring device as a whole or in part is made of a bio-compatible material, such as a bio-compatible metal or a metal alloy, for example titanium, stainless steel, a nickel-titanium alloy, for example, Nitinol, or of a bio-compatible plastic material, such as, for example, from the group of polyaryletherketones, for example polyetheretherketone (PEEK).

Referring now to FIGS. 20 to 23, the receiving part may be pre-assembled with the sleeve-like insert piece 5 and the cap member 6 as well as the rod receiving element 7 in the -following manner. First, as shown in FIG. 20, the sleeve-like insert piece 5 is inserted from the top end 4 a into the receiving part in a tilted orientation, i.e. the central axis 5 c of the sleeve is perpendicular to the central axis C of the receiving part 4. The sleeve-like insert piece 5 is furthermore inserted in such an orientation that it extends into the recesses 47 a, 47 b of the receiving part. Next, as shown in FIG. 21, when the sleeve-like insert piece 5 extends at least partially through the lower opening 45 of the receiving part 4, it is tilted such that it can assume in the accommodation space 44 an orientation where its central axis 5 c is coaxial with the central axis C of the receiving part 4, as further depicted in FIG. 22. Then, the cap member 6 is inserted from the top end 4 a into the receiving part until the lower part of the first portion 61 is held in the central spherical portion 52 of the sleeve-like insert piece 5, as also depicted in FIG. 22, In the next step, as shown in FIG. 23, the rod receiving element 7 is inserted from the upper end 4 a into the passage 41 such that the recess 71 for receiving the rod 100 is aligned with the recess 42 of the receiving part 4. Subsequently, the pin 9 is inserted into the pin hole 48 until it engages the elongate recess 75 at one of the legs 71 b of the rod receiving element 7. By means of this the rotational position of the rod receiving element 7 is secured and the rod receiving element 7 is secured against escaping through the top end 4 a of the receiving part 4.

The orientation in which the enlarged pivot angle is provided, can be adjusted by rotating the cap member once it has been inserted into the receiving part 4 or after inserting the head into the cap member.

The circumferential projection 76 on the legs 71 a, 71 b of the rod receiving element 7 is in a position above the undercut 49 when the cap member 6 is in an insertion position for the head 3, as shown in FIGS. 23 and 24.

In the next step, the bone anchoring element 1 is connected to the receiving part 4. Either, the bone anchoring element 1 has been already inserted into a bone part or a vertebra and the receiving part 4 is mounted onto the head 3 of the bone anchoring element in situ at the operation site or the bone anchoring element is connected beforehand to the receiving part 4 and thereafter inserted into the bone or vertebra. As shown in FIGS. 24 and 25, the head 3 is inserted through the sleeve-like insert piece 5 into the interior chamber 62 of the cap member 6. Thereby, the cap member 6 is moved upward toward the upper end 4 a of the receiving part 4 until it abuts with its upper end 6 a against the lower end 7 b of the rod receiving element. This moves the rod receiving element slightly upward until the bottom 75 a of the elongate recess abuts against the pin 9. The projection 76 extends into the space between the crests of the inner thread 43 of the receiving part 4 and is thus allowed to move in an axial direction in that space. When the head 3 enters the hollow interior chamber 62, the first portion 61 of the cap member 6 expands within the upper tapered portion 55 of the sleeve-like insert piece 5 until the head 3 has fully entered the interior chamber 62, as depicted in FIG. 26.

In a next step as shown in FIG. 27, the rod receiving element 7 is moved downward and shifts the cap member 6 with the inserted head 3 into the central spherical portion 52 of the sleeve-like insert piece 5. The rod receiving element 7 is pressed downward, until the upper surface 76 a of the projection 76 snaps into the undercut 49. In this position, the lower edge 49 a of the undercut 49 retains the rod receiving element 7 so that it cannot move upward again. Simultaneously, the first portion 61 of the cap member 6 is compressed by the sleeve-like insert piece 5 to such an extent, that the lower opening of the sleeve-like insert piece 5 is narrowed so that the head 3 cannot be removed from the receiving part. This is the pre-locking position of the cap member. Because the head 3 is held by friction within the first portion 61 of the cap member 6, the receiving part 4 can be manually or in another way pivoted relative to the bone anchoring element while the relative angular position of the bone anchoring element 1 to the receiving part 4 is maintained in a preliminary manner.

In the pre-locking position of the cap member 6, the head 3 is pivotabie relative to the receiving part 4 in all directions. When the head 3 pivots with respect to the receiving part 4, the shank 2 of the bone anchoring element 1 abuts against the lower portion 54 of the sleeve-like insert piece 5. Thereby, the sleeve-like insert piece 5 pivots in the seat 46 of the accommodation space 44 of the receiving part 4 as shown in FIG. 27. The bone anchoring element 1 can pivot to the side comprising the slanted lower edge portion 65 at a greater angle than in an opposite direction. The enlarged pivot angle α defined as the maximum angle that the shank axis S can include with the central axis C of the receiving part 4 may be equal to or greater than 40° measured from the central axis C. When the head 3 pivots in the cap member 6, a portion of the head 3 may extend into the coaxial bore 67 of the cap member.

Finally, the rod 100 is inserted into the receiving part and the rod receiving element 7 and the locking element 8 is inserted into the receiving part 4. For a two-part locking element 8, as shown in FIG. 1, the first locking element 8 a acts onto the upper end 7 a of the legs 71 a, 71 b of the rod receiving element 7. If the first locking element 8 a is tightened, the pressure is transmitted through the rod receiving element 7 and the cap member 6 onto the head 3 and the sleeve-like insert piece 5. By means of this, the sleeve-like insert piece 5 is pressed into the seat 46 of the accommodation space 44. When the first locking element 8 a is finally tightened, the head 3 in the cap member 6 and the sleeve-like insert piece 5 in the accommodation space 44 are both locked so that the position of the bone anchoring element 1 relative to the receiving part is fixed. Tightening of the second locking element 8 b fixes the rod 100. With the solid, non-elastic sleeve-like insert piece 5 the construct is more robust and can take up higher locking forces compared to a device with a flexible sleeve or a flexible cap member only.

Instead of the two-part locking device 8, a single part locking device (not shown) can be used that may consist of, for example, a set screw with a central projection that acts onto the rod only. The pressure exerted by the single part locking device is transferred to the rod 100 onto the rod receiving element 7 and the cap member 6. The rod 100 and the head 3 can be fixed simultaneously. Other kinds of locking devices may be contemplated, for example, a sequential locking device that comprises a single drive portion only and that fixes the head and the rod sequentially.

In the clinical use, at least two bone anchoring elements are anchored in a bone or in adjacent vertebrae and connected by a rod. In one embodiment, the surgeon or any other personnel can select a desired bone anchoring element and combine it with the pre-assembled receiving part with sleeve-like insert piece, cap member and rod receiving element. The design of the bone anchoring device allows the selection of an appropriate bone anchoring element in terms of diameter, length, and other features. Furthermore, a suitable locking device may be selected. Hence, a modular system is provided which includes various elements which individually can be chosen and adapted.

A further embodiment of the cap member will be described with reference to FIGS. 28 to 31. The cap member 6′ differs from the cap member 6 in the design of the slits. Instead of a plurality of longitudinal slits, one or more substantially horizontally extending slits are provided. The cap member 6′ has a first substantially vertical slit 640 a that extends from the lower edge 6 b and opens into a substantially horizontal slit 640 b that extends around the central portion in a slightly slanted manner until a first end (not shown) on one side and a second end 640 d at a second side. The substantially vertical slit 640 a may be preferably at the side where the slanted lower edge 65 is provided. All other parts of the cap member 6′ are the same and have the same reference numerals and the description thereof will not be repeated. The receiving part and the rod receiving element are the same as for the first embodiment. With the cap member 6′ according to the second embodiment an insertion force that is necessary to insert the head into the cap member 6′ may be reduced compared to the cap member 6 of the first embodiment while the holding force in the pre-locking position may be the same or similar for both cap members.

Various modifications of the embodiments described before may be contemplated. The receiving part is not limited to the exact shape as shown. The recess 42 does not have to have an exact U-shape. The retaining elements can be realized otherwise, for example through spring portions, snap rings or other constructs that prevent movement of the rod receiving element and the receiving part relative to each other.

The head 3 and correspondingly the interior chamber 62 of the cap member 6 can have another shape. For example, two opposite flattened portions may be present that render the pivot connection rnonoplanar.

Various different kinds of anchoring elements can be used and combined with the receiving part. These anchoring elements may be, for example, screws with different length, screws with different diameters, cannulated screws, screws with different thread forms, nails, hooks, etc. For some anchoring elements, the head and the shaft may also be separate parts that are connectable to each other.

All kinds of rods can be used. While rods with a smooth surface are shown, roughened rods or rods having a structure may be used. The rods may also be flexible rods.

While a number of different embodiments are disclosed herein, it is appreciated that different components from the different embodiments can be mixed and matched to produce a variety of still other different embodiments.

While the present invention has been described in connection with certain exemplary embodiments, it is to be understood that the invention is not limited to the disclosed embodiments, but is instead intended to cover various modifications and equivalent arrangements included within the spirit and scope of the appended claims, and equivalents thereof. 

1. A polyaxial bone anchoring device including an anchoring element having a shank for anchoring in the bone and a head, the head comprising a spherically-shaped outer surface portion; a receiving part configured to be pivotably connected to said head, the receiving part having a first end, a second end, a central axis extending through the first end and the second end, a channel for receiving a rod, an accommodation space for accommodating the head, the accommodation space having a lower opening at the second end, and a coaxial passage extending from the first end into the accommodation space, a cap member that is arranged at least partially in the accommodation space, the cap member having a first portion that is configured to be positioned at least partially around the head, wherein the first portion is expandable in the accommodation space to allow insertion of the head and compressible to exert pressure onto the head; a sleeve-like insert piece configured to be positioned at least partially around the first portion of the cap member, wherein the sleeve-like insert piece comprises a spherically-shaped outer surface portion and is configured to pivot in the receiving part.
 2. The polyaxial bone anchoring device of claim 1, wherein the first portion of the cap member comprises a hollow interior space with a spherically-shaped inner wall portion for accommodating at least a portion of the head therein and a lower opening for inserting the head and wherein the lower opening comprises a bounding edge with a portion that is configured to allow the head to pivot at a greater angle in one direction compared to another direction.
 3. The polyaxial bone anchoring device of claim 2, wherein the cap member comprises an indication mark that is configured to indicate the orientation of the portion of the bounding edge allowing the greater pivot angle when the cap member is inserted into the receiving part.
 4. The polyaxial bone anchoring device of claim 1, wherein the size of the cap member is such that the head is held in the cap member by friction once the head is inserted into the first portion of the cap member.
 5. The polyaxial bone anchoring device of claim 1, wherein the cap member is rotatable in the receiving part when the first portion is not compressed.
 6. The polyaxial bone anchoring device claim 1, wherein the cap member comprises a second portion that has a substantially flat, ring-shaped surface facing toward the first end of the receiving part.
 7. The polyaxial bone anchoring device of claim 1, wherein the sleeve-like insert piece comprises a lower edge that extends past the lower opening of the accommodation space in a direction away from the receiving part when the insert piece is seated in the receiving part in a position in which the central axis of the insert piece is coaxial with the central axis of the insert piece.
 8. The polyaxial bone anchoring device of claim 1, wherein the sleeve-like insert piece has an opening with a diameter that is greater than or equal to a maximum diameter of the first portion of the cap member when the head is inserted into the cap member.
 9. The polyaxial bone anchoring device of claim 1, wherein the sleeve-like insert piece has a spherically-shaped inner surface portion that is configured to cooperate with a spherically-shaped outer surface portion of the first portion of the cap member such that the insert piece can pivot with respect to the cap member when the head is inserted into the first portion of the cap member.
 10. The polyaxial bone anchoring device of claim 1, wherein when the head is inserted into the cap member, the insert piece is pivotable with respect to the central axis of the receiving part and with respect to a longitudinal axis of the anchoring element, and wherein the anchoring element is pivotable with respect to the central axis of the cap member, and wherein the anchoring element and the insert piece can be locked at respective angles to the central axis of the receiving part by exerting pressure with the cap member onto the head and onto the insert piece.
 11. The polyaxial bone anchoring device of claim 1, further comprising a rod receiving portion positioned in the passage between the cap member and the first end of the receiving part.
 12. The polyaxial bone anchoring element of claim 11, wherein the rod receiving portion is configured to transmit a pressure force onto the first portion of the cap member.
 13. The polyaxial bone anchoring device of claim 11, wherein the rod receiving portion comprises a channel for receiving the rod and wherein a first retaining element is provided that acts between the rod receiving portion and the receiving part to prevent the rod receiving portion from escaping through the first end of the receiving part and that is preferably configured to hold the channel for receiving the rod of the rod receiving portion and the channel of the receiving part aligned.
 14. The polyaxial bone anchoring device of claim 11, wherein a second retaining element is provided that acts between the rod receiving portion and the receiving part to hold the first portion of the cap member in a position with respect to the sleeve-like insert piece in that a removal of the head from the cap member is prevented.
 15. The polyaxial bone anchoring device of claim 11, wherein the channel for receiving the rod of the rod receiving portion comprises sidewalls that extend above the upper surface of an inserted rod.
 16. The polyaxial bone anchoring device of claim 11, wherein the rod receiving portion is a separate part that comprises a lower surface portion facing an upper surface portion of the cap member and cooperating therewith to transmit pressure onto the cap member. 